Provider Demographics
NPI:1154379089
Name:STEIN, ELLIOTT MARTIN (MD)
Entity type:Individual
Prefix:DR
First Name:ELLIOTT
Middle Name:MARTIN
Last Name:STEIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:535 MIDVALE WAY
Mailing Address - Street 2:
Mailing Address - City:MILL VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:94941-3705
Mailing Address - Country:US
Mailing Address - Phone:415-672-9352
Mailing Address - Fax:
Practice Address - Street 1:535 MIDVALE WAY
Practice Address - Street 2:
Practice Address - City:MILL VALLEY
Practice Address - State:CA
Practice Address - Zip Code:94941-3705
Practice Address - Country:US
Practice Address - Phone:156-729-3524
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-04
Last Update Date:2021-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG279642084P0800X, 2084P0805X
FLME 304362084P0800X, 2084P0805X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric Psychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL92798OtherBLUE CROSS/BLUE SHIELD FL
FL059518700Medicaid
FL92798OtherBLUE CROSS/BLUE SHIELD FL
593377839OtherFEDERAL EIN
FL059518700Medicaid